Turf war leads to ousting of ER docs

An ongoing power struggle between Haywood Regional Medical Center CEO David Rice and doctors in the emergency room came to a head last week when the hospital board, at Rice’s recommendation, voted to hand over ER operations to a corporate physician staffing company.

The hospital is terminating its contract with the local group of doctors despite 18 months remaining on their contract. The physician staffing company is slated to assume responsibility for the ER on Dec. 28, but as of Monday it did not have any doctors lined up.

“It is a challenge, but it is one that will be met,” said Chris Lutes, president of Phoenix Emergency Physicians, the company that will take over emergency operations at HRMC.

The push to replace Haywood Emergency Physicians is appalling, said Mark Jaben, a long-time ER doctor and spokesman for the group.

“The emergency department is a tightly choreographed affair,” Jaben said. “They are going to drop these new doctors into a department where they don’t know how it runs. They don’t know the nurses. They don’t know the computer system. And they are going to do it on one of the busiest holiday weekends of the year.”

Rice said he hopes many of the current ER doctors will stay and work with the new company. Jaben said few of the doctors in his group are interested, however.

Rice said the decision to replace the ER doctors is necessary for the long-term solvency of the hospital. Rice said the ER doctors have been generally uncooperative in implementing hospital initiatives, such as a new computer system and efforts to reduce patient wait time.

“I think the community will understand we had no other option than to do what we had to do,” Rice said.

Meanwhile Jaben said Rice has attempted to micromanage ER operations and interfered with doctors’ autonomy. The ER doctors objected and are now being ousted as a result, Jaben said.

Some doctors in the community are not happy with the decision to terminate the contract of the ER group.

“I certainly love this group,” Dr. Slobodan Jaseravic, a surgeon, said of the local doctors. “We are working with them very, very well. They are very kind and professional at all times. As far as I am concerned I want them to stay.”

The emergency doctors believe they have the support of patients as well. Jaben was accosted by such a supporter while driving down the road Monday. A car he didn’t recognize veered toward him, flashing its headlights and taking up more than its share of the road. Jaben slowed down and rolled down his window as the other driver pulled alongside him. The man had seen a story on the ousting in The Mountaineer that morning.

“He said, ‘Whatever I can do to help, just let me know. I was in that hospital and you guys saved my life,’” Jaben recounted. Jaben didn’t even know the man.

The story is far from over. The doctors could sue the hospital for a breach of contract, and a movement within the medical community to oppose Rice could be brewing.

Mark Leonard, the president of WestCare, said a positive working relationship between doctors and hospital administration is important.

“We have a strong culture of collegiality over here,” Leonard said of Harris Regional Hospital in Sylva. “We have differences and tension but the ability to work through that is strong. We are very aligned and are focused.”

The same could not be said of Haywood’s ER doctors and Rice.

Ultimate authority

The hospital board voted last week to terminate its contract with the ER doctors after the group would not agree to a rewrite of the contract. The ER doctors felt several clauses in the proposed contract gave Rice too much control over ER operations that were best left up to the doctors.

ER doctors aren’t employees of a hospital. Instead, they work for a private practice, and the hospital contracts with that practice to staff the emergency department.

The primary deal-breaker in the contract would give Rice authority to remove an ER doctor. The contract did not spell out specific instances that would warrant such action, but instead left it open-ended and up to Rice’s discretion.

“What Mr. Rice is trying to develop is a command and control structure,” Jaben said.

The conflict between hospital administrators and doctors is not unique to Haywood County.

“This tussle is playing out all around the country,” Jaben said. “The economics of health care have gotten so tight that administrators think they need to control every aspect of medical care to control their finances.”

That’s one reason the ER doctors objected. Doctors should have one interest at heart: patient care. Hospital administrators, meanwhile, are partial to the bottom line, Jaben said. Giving the CEO power to remove a doctor opens the door to meddling in a doctor’s decisions regarding a patient, such as ordering unnecessary tests to make money or discharging patients who can’t afford treatment.

“He could force decisions that are not in the best interest of patient care,” Jaben said.

A national advocacy group for ER doctors is against any provisions that give a CEO power to unilaterally remove a doctor.

“It subtly but effectively gives that hospital administrator influence over a physician,” said Dr. Joseph Wood, an ER doctor at the Mayo Clinic and the past president of American Academy of Emergency Medicine.

Necessary tool

Rice said the provision would never be exercised in the hypothetical scenarios the ER doctors suggest.

“It’s not that we would just walk in and arbitrarily hack somebody off,” Rice said. “I wouldn’t want that privilege in the first place. It’s a reckless way to do business.”

The spirit of the language is meant to protect the hospital. What if a doctor was charged with a crime, sexually harassed a nurse, or was sloppy in his work? If the hospital attempted to spell out every feasible scenario in which a doctor could be removed, it might leave out an important one. That would merely be fodder for a lawsuit, so the hospital kept the wording broad, according to hospital administration.

Rice said it could be necessary to get rid of physicians who don’t work well within their team of doctors or with the hospital.

Dr. Nancy Freeman, chairman of the hospital board, said the clause is in every contract the hospital has with other doctors that manage operations with a hospital, such as anesthesiology, hospitalists, and radiology.

Dr. Richard Lang, a radiologist, said he doesn’t have a problem with the clause. It allows the CEO to remove a doctor at his discretion with two months notice.

“We don’t have problem with that,” Lang said of his team. “If we come in every day and work hard and are nice to our patients they would never think of getting rid of us. It doesn’t bother us because we have such trust in the administration that if they ask us to leave, we probably deserve to leave.”

Lang said the clause can be beneficial to a group of doctors as well. Sometimes a group can get stuck with a prima donna doctor who is hard to work with. It is often difficult for a group to kick such a doctor out of their practice, and the practice can be held hostage by a doctor they don’t like.

Requiring cause for removal would weaken the purpose of the tool, Lang said.

“How do you define cause? They don’t want to sit there and spend three or four years arguing cause,” Lang said.

Eye of the beholder

Jaben said removing a doctor deemed uncooperative by the hospital administration is in the eye of the beholder.

“When Mr. Rice wants to enforce policies and procedures that are contrary to good patient care and the caregivers have legitimate concerns about those, then the caregivers have every right to stand up for their patients,” Jaben said. “But if you stand up and try to represent something that doesn’t work well and the CEO doesn’t like it, you could be fired.”

Jaben said there have been several instances like this in the ER over the past two years.

The provision is not intended as a safeguard against reckless patient care, Jaben said. If patient care is jeopardized by a doctor, mechanisms are already built into the bylaws of the hospital that would allow for an immediate suspension, followed by a hearing before a committee of other doctors. A provision that allows a CEO to remove a doctor without cause and without the ability to appeal the decision to an independent committee of other doctors is a much different animal, Jaben said.

Rice said the provision has become the industry standard.

But Dr. Joseph Wood, an ER doctor at the Mayo Clinic, disagreed.

“That’s not to say you won’t find that in other contracts, but it is not widespread,” Wood said.

Harris Regional Hospital in Sylva does not have such a clause, according to Mark Leonard, the president of WestCare.

“With a decision of that magnitude, we would want to make sure there are a number of other folks involved, such as the medical staff leadership and board leadership,” Leonard said.

Rice said Phoenix agreed to the provision that gives the CEO power to remove a physician.

Lutes, the manager for Phoenix, said all the hospitals Phoenix works in have a provision that allows hospital administration to remove a physician, but he stopped short of calling it an industry standard.